Bone-on-bone, Part 2: Should we ever say it? (Member Post)

• Jul 3, 2024 • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Back in May, I published the first part of a deep dive into the notorious words bone-on-bone (BOB), which are often used to describe severe osteoarthritis. Sometimes it is accurate: joints can lose all their cartilage. But the goal of that post was to try to figure out how often BOB is a bogus exaggeration. The answer? It’s probably routine.

Part 1 was a members-only post. I’ve now let it out of the pay-pen, and it is now free for everyone, the first half of a new permanent article devoted to this topic: Bone on Bone: How often are those dirty words about arthritis a harmful exaggeration? And should we ever use them, even when it’s accurate? (You might want to read that before continuing here.)

Part 2 finishes the job below (and in the article): even when BOB is actually true, does that justify ever actually saying it? And this part is also for members-only, at least for now.

Introduction: My BOB bias, Buddhism bloopers, and the joy of heaping scorn on bad words

There are strong reasons to avoid the words “bone-on-bone,” and I’ll review those below. This has been my bias for years — not a strong one, but clear.

But there are also reasons some why BOB should be spoken, sometimes — reasons I discovered as I explored this topic. I will retract my attempt to bolster my bias with the Buddhist wisdom I quoted in part 1, because I got that wrong, and now I'll use it to argue the other way! To my surprise, I don’t think BOB deserves all the scorn that gets heaped on it.

And the scorn does get heaped!

It has become fashionable for healthcare professionals to virtue signal with their outrage about how often arthritis is described as “bone on bone.” In their zeal, they can end up minimizing severe arthritis itself, which is going too far… and then often brain-blaming instead, which strikes me as just replacing one nocebo with another.

For instance, a physiotherapist ranting about this on social media wrote that he “hates” BOB, and that the words are “simply referring to the presence of some degeneration.”

Some? Some?! That’s like saying a third degree burn is “simply referring to the presence of some discolouration.” BOB clearly doesn’t just mean “some” degeneration — it means a lot of degeneration!

Then he cited Culvenor et al. to prop up his point that BOB’s not so bad: “up to 43%” of older asymptomatic people had signs of arthritis. But those pain-free people had any sign, not signs of severe arthritis. BOB isn’t as bad as people think, but this isn’t the way to make that point. He needed a much different study, showing how many asymptomatic people have severe signs of arthritis!

But no such study exists.

Meanwhile, clearly severe arthritis does exist, and can be extremely painful, and bullshitting people about that isn’t helping anyone.

So how should severe arthritis be described? Well, a Buddhist would say “it depends”…

MEMBERS-ONLY AREA

Would the Buddha say “bone-on-bone”? A 2600-year-old lesson in medical ethics and communication

In part 1, I wrote that there is a “Buddhist tenet” that you should ask yourself if what you have to say is true, helpful, and kind — implying that BOB probably doesn’t meet those criteria, and therefore Buddha has your back if you think BOB should never be said. It’s nice to have a Buddhist endorsement for your position, isn’t it?

I got it wrong, though. I’m no Buddhist scholar. I didn't know that the true/helpful/kind version was greatly dumbed down until reader Paul O. pointed out that there are actually six rather complicated criteria for deciding what is worth saying … and the original, he writes, “makes your ‘kindness’ criterion on its own misleading.”1 So yeah… I used oversimplified ancient wisdom to score a cheap point, didn’t check my source, and got busted!

But I love getting schooled, and the actual citation is so much more interesting.

The Buddha mostly advises against speaking, but there’s specifically an exception for using words that are beneficial despite being hard to hear! Beneficial bad news is allowed! Maybe!

In such cases, the Buddha was indeed inclined to speak, but (and I love this) with “a proper sense of timing.”

Indeed.

And what if words are not beneficial, despite being true? Well, in that case, “he does not say them”! Kindness is beside the point. What counts is the benefit. Fascinating. And, somewhat hilariously, even six detailed tenets still basically boils down to it depends.

So is it beneficial to speak of “bone-on-bone”? Or not? (And what’s the right timing?)

Classy B&W photo of the Great Buddha of Kamakura.

This photo of the Great Buddha of Kamakura was taken by my father, Bob Ingraham, while he was stationed in Japan with the US Navy, before being shipped off to Vietnam, where a bullet destroyed his femur and set him up for knee arthritis in a big way … which I will bring up again below as a good BOB case study.

Specifically, it depends on the symptoms

Probably no one with minor symptoms should ever be told that their arthritis is severe, in any words, “bone-on-bone” or otherwise — it’s too discouraging for someone who still has too much cause to be optimistic.

It is possible to have minor symptoms with what looks like severe arthritis on an x-ray. These patients can have an excellent prognosis. Many will have rough patches, but — if you don’t tell them — some people will never even know that they have “severe” arthritis (or not for quite a long time).

Severe arthritis can be mild? Citation needed, but it’s missing. I’m afraid that there is no direct evidence of this to the best of my knowledge. It seems patently obvious from my own clinical experience, and talking to many experts over the years, but I can’t point to hard prognosis data to back it up. Strangely. As far as I can tell, no one's bothered to check. Maybe someday.

SO I believe there is plenty of hope for many people with BOB. And, for those who have only experienced minimal suffering so far, I don’t think that hope should be preemptively menaced with the melodrama of BOB.

Saying “bone-on-bone” can really spook people

There are also reasons to avoid saying BOB even when a patient is already suffering quite a lot. It’s hard to overstate the degree to which BOB intimidates people.

People cannot easily “un-see” anything that is revealed by any imaging, nor “un-hear” an intimidating interpretation of it. Once BOB has been shown/said, it is often just game-over for nuance. We are strongly prone to thinking, “Welp, that’s it for that joint! It’s just useless now, and there’s no hope, and I have to be super careful with it for the rest of my life. No more walks for me.”

That’s a bad take even for people in a lot of pain.

But that kind of thinking may still happen, even with a big effort to discourage it. People are easily misled in the direction of the fearful belief that their body is like a fragile machine that wears out and breaks down — because that simplistic model is amazingly prevalent in our world, familiar and seductive. It is essentially the only thing that most people think they know about musculoskeletal medicine.2

All our lives, we are inundated with ideas and advice and therapies and products that harmonize with that. We need to be stabilized, aligned, braced, balanced, adjusted! It’s wrong in so many ways … and yet still overwhelmingly dominant in orthopedics, sports medicine, and all the manual therapies.

In other words, BOB harmonizes powerfully with existing fears and misconceptions, making it a bit of a psychological wrecking ball.

Bone-on-bone isn’t anywhere near as bad as it sounds — but being “scared still” is a disaster!

The main argument against BOB-saying is that it doesn't just spook people, but specifically spooks them into sedentariness and disability that is going to make things worse, not better.

As mentioned, severe joint degeneration is not a death sentence for a joint. Advanced arthritis can have surprisingly mild symptoms, symptoms that come and go over the years. How it progresses has more to do with general health and fitness than wear and tear.

Not only are we not fragile, but fearful sedentariness discourages exactly what people need most: as much activity as pain reasonably allows! Bunzli et al.:3

“Common misconceptions about knee arthritis appear to influence patients’ acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been ‘diagnosed’ with ‘bone-on-bone’ changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage.”

Osteoarthritis is not a “wear-and-tear” disease. How do we know this? Many ways:

Osteoarthritis is almost twice as common as it was before the industrial revolution, but not because of stress on joints.4
It’s obviously not mainly about stress on joints, because it’s very prevalent in obese people … in the hands!5
And walking and running don’t make it worse!6
If it’s not the wear and tear, then what is it? Well, there’s a link between heart disease and osteoarthritis.7
Summing all that up in broad strokes, a 2023 scientific review by Lynskey et al. compiled a pile of evidence showing that seemingly mechanical conditions like arthritis and tendinopathy are much more about metabolic health than physical stresses.8 Arthritis is basically an inflammatory disease.9

And so sedentariness and being out of shape is much more dangerous than overdoing it occasionally with your bum knee. Which means that it’s a terrible idea to unnecessarily scare people away from their well-known best option: staying active.10 It’s not that exercise is a miracle cure for arthritis, severe or otherwise — it’s not11 — but it is vital for other well-established reasons,12 and so it’s a disaster if people avoid loading that isn’t the problem.

Here’s the same message in different words from Dr. Howard Luks, an orthopedic surgeon who admirably operates as little as possible:

Telling a patient that they have “bone on bone” X-rays or that they possess the knee of a 90-year-old is more harmful than informative. While attempting to convey the severity of the condition, these phrases can, and often do, inadvertently lead to a fear-driven cessation of all physical activities. Running does not cause arthritis to worsen. It just doesn’t. As I often tell people in my office who think that running led to the need for a knee replacement. Your running didn’t lead to your knee replacement; your running enabled you to keep your natural knee much longer than you would have otherwise.

When patients hear that their joints are severely deteriorated, they might believe the best course of action is to reduce or completely stop activities to “preserve” their knees. This belief is perhaps well-intentioned, but it is counterproductive and wrong. As mentioned earlier, OA is not primarily a result of mechanical stresses but a biological issue related to cartilage repair mechanisms and inflammation. Consequently, inactivity may worsen metabolic health, thereby increasing inflammation and exacerbating OA. The risks associated with inactivity are far more consequential than those associated with exercising.

Contrary to the notion of preserving joints through inactivity, staying active has numerous benefits for those with OA.

The power of BOB spooks people into surgery they don’t need yet (and might never)

Joint replacement is the right choice for some people, but I think it’s fair to say that it’s over-prescribed (see part 1, and Knee Replacement Surgery Doubts). It’s just not as good a solution as we’d like, to a problem that is routinely not as bad as we think. Anything that inflames that over-prescription is best avoided.

Exaggerated claims of bone-on-bone are obviously a major culprit. Surgery would plummet if no one ever heard BOB when it was bullshit.

But even when BOB is true, it effortlessly moves the emotional needle towards more drastic solutions. Desperate times call for desperate measures, right? So maybe we should avoid strongly implying with the power of BOB that times are “desperate”!

Why might saying bone-on-bone be okay sometimes? (At the right time, in the right way.)

You can’t avoid it! There are clinical scenarios where it might make sense to talk about BOB judiciously.

Most obviously, patients talk about BOB. Often because some professional has already spilled the BOB beans. They'll bring it up!

The phrase is so unavoidable that maybe it’s just good proactive damage control to get out in front of it. Acknowledge and reassure! “BOB is often bullshit, so let’s talk about it. Yes, technically you have BOB … but … ”

The Brain Blamers: BOB-denial can be gaslighting

The refusal to say BOB often comes with a well-known way of pain gaslighting: attributing pain to something other than the state of the joint. If not the joint tissues, then what?

The mind, of course. Fearfulness. These clinicians are the Brain Blamers.

Many professionals are surprisingly keen to minimize the role of pathology and injury in pain (secondary pain), the better to overzealousy (and conveniently) blame it on the power of the mind/brain to “amplify” pain (primary pain, “nociplastic” pain, in which pain itself is the disease).13 When professionals talk about this in the office — maybe in a general way, or maybe as a more deliberate attempt to Explain Pain — the subtext is always “you’d be fine if you weren’t so scared of your knees.”

And sometimes it’s just the text. It sounds ridiculous, but I’ve heard it said in earnest with my own ears, in my own clinical situation — and I’ve heard from countless readers about being subjected to such bollocks. This is a phenomenon that more and more professionals are starting to push back against (like this very fresh example, a Facebook post).

The mind is involved in pain in a variety of ways, no doubt.14 But I doubt it’s responsible for most arthritis pain, and I think we should avoid implying that by scoffing too hard at BOB, like it doesn't matter. BOB matters a lot.

What if the truth was reassuring?

Patients are unanimous: “don’t bullshit me.” They want healthcare professionals to “tell it like it is.” The idea of minimizing the seriousness of a condition is appalling to most people in principle. We don’t necessarily know what’s good for us, and most of us like to think that we are tougher than we actually are … but we can smell comforting bullshit a mile away, and they will be annoyed by it, whether they should be or not.

Candidly “telling it like it is” also isn’t necessarily scary (or not only scary). There is another possible emotional reaction that’s quite valuable: the cold hard truth might also be validating and empathetic. When patients have severe pain, they like having a severe explanation. Paradoxical relief is a real thing. Uncertainty and frustration are a huge part of having chronic pain, even a common kind like arthritis. The clarity offered by a vivid explanation for pain can be a relief despite the bad news.

One of the principle qualities of pain is that it demands an explanation.
Plainwater, by Anne Carson

So frankness about BOB can really work well for a certain kind of patient.

But it should be followed by frankness about the fact that it is often not nearly as bad as it sounds, and strong encouragement to remain as active as possible.

Bob has BOB

While I was working on this article, I had a long conversation with my father, who is named Bob, and has BOB — or so he has been told. Bob has BOB! Or does he?

Either way, he is not living very peacefully with his arthritis lately.

We talked about the highs and lows, about the capricious nature of it, and how to account for that. Despite being told he had BOB a long time ago, twenty years or something, he has now lived with his “severe” arthritis for many years … and it often doesn’t feel severe. But then it does again for a while. And then it stops. It comes and goes on the tides of unknown physiological variables. And probably emotional ones, too (the brain gets some blame).

So the conversation was all about how his pain is not “all in his mind” or “all in his joints.” It’s always a hybrid. Which often results in surprisingly low pain and high function despite what looks like cartilage carnage.

But it also often results in high pain and low function! Such is life. Many kinds of pain come and go and then come again.

BOB is complicated. And so there is no simple answer to whether or not to say it. It’s like the Buddha said: “It depends.”

So is BOB a nocebo or not?

It definitely can be. Without context and empathy, xx it probably is. In many cases, it probably does do real harm. It isn’t out of place on a list of noceboes.xxx

But it’s probably a bad idea to demonize it as a terrible nocebo, without nuance. Because it is real sometimes, and because the term can’t be avoided anyway, and because it is often avoided for gaslighty reasons — excessive brain-blame — and because it can also be declawed and used to validate, empathize, and just, y’know, not bullshit.

Notes

Bodhi, B. (Trans.). (1995). The Middle Length Discourses of the Buddha: A Translation of the Majjhima Nikāya. MN 58. Wisdom Publications.
The six criteria for deciding what is worth saying are as follows:
1. “In the case of words that the Tathagata knows to be unfactual, untrue, unbeneficial (or: not connected with the goal), unendearing & disagreeable to others, he does not say them.
2. “In the case of words that the Tathagata knows to be factual, true, unbeneficial, unendearing & disagreeable to others, he does not say them.
3. “In the case of words that the Tathagata knows to be factual, true, beneficial, but unendearing & disagreeable to others, he has a sense of the proper time for saying them.
4. “In the case of words that the Tathagata knows to be unfactual, untrue, unbeneficial, but endearing & agreeable to others, he does not say them.
5. “In the case of words that the Tathagata knows to be factual, true, unbeneficial, but endearing & agreeable to others, he does not say them.
6. “In the case of words that the Tathagata knows to be factual, true, beneficial, and endearing & agreeable to others, he has a sense of the proper time for saying them. Why is that? Because the Tathagata has sympathy for living beings.”
“Structuralism” is the excessive focus on crookedness and “mechanical” problems as causes of pain. It has been the dominant way of thinking about how pain works for decades, and yet it is a source of much bogus diagnosis. Structuralism has been criticized by several experts, and many studies confirmed there are no clear connections between biomechanical problems and pain. Many fit, symmetrical people have severe pain problems! And many crooked people have little pain. Certainly there are some structural factors in pain, but they are generally much less important than messy physiology, neurology, psychology. Structuralism remains dominant because it offers comforting, marketable simplicity. For instance, “alignment” is the dubious goal of many major therapy methods, especially chiropractic adjustment and Rolfing. See Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
Bunzli 2019, op. cit.
Wallace IJ, Worthington S, Felson DT, et al. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A. 2017 Aug;114(35):9332–9336. PubMed 28808025 ❐ Knee osteoarthritis is thought of as a “wear-and-tear” problem aggravated by weight and age. In this experiment, this assumption was tested for the first time using “long-term historical or evolutionary data.” They looked at the skeletal remains of older people with a well-documented body mass index from the last two centuries (industrial and post-industrial); they also looked at prehistoric knees. The prevalence of osteoarthritis has roughly doubled in recent history (20th century) — and that number didn’t change when weight and age were factored out. The implications are clear: loading and longer lifespans are almost certainly not the cause of knee arthritis!
Jiang L, Xie X, Wang Y, et al. Body mass index and hand osteoarthritis susceptibility: an updated meta-analysis. Int J Rheum Dis. 2016 Dec;19(12):1244–1254. PubMed 28371440 ❐
Voinier D, White DK. Walking, running, and recreational sports for knee osteoarthritis: An overview of the evidence. Eur J Rheumatol. 2022 Aug. PubMed 35943452 ❐
Voiner and White reviewed a lot of reviews of the relationship between exercise and arthritis — an “overview of narrative reviews, systematic reviews, and meta-analyses,” twenty of them. They also threw a dozen original trials into the mix. Their clear conclusion, based on “consistent evidence,” is that arthritis just has nothing to do with common kinds of physical activity and exercise, like walking and running and playing softball. Specifically, the “structural progression” is unrelated to physical activity in the general population.
Mathieu S, Couderc M, Tournadre A, Soubrier M. Cardiovascular profile in osteoarthritis: a meta-analysis of cardiovascular events and risk factors. Joint Bone Spine. 2019 Nov;86(6):679–684. PubMed 31323333 ❐
Lynskey SJ, Macaluso MJ, Gill SD, McGee SL, Page RS. Biomarkers of Osteoarthritis-A Narrative Review on Causal Links with Metabolic Syndrome. Life (Basel). 2023 Mar;13(3). PubMed 36983885 ❐ PainSci Bibliography 51282 ❐
Physiology and biochemistry more than anatomy and biomechanics. Take two people with the same physical stresses on the knee and it’ll probably be the borderline diabetic who gets the knee osteoarthritis first.

So what goes wrong with “metabolic health”? It’s a mash-up of what most people know as your risk of heart disease and diabetes — all familiar stuff. You know your metabolic health might be mangled when you are “out of shape” — high blood sugar, high blood pressure, lots of cholesterol in your blood and belly fat. You get out of breath taking a flight or two of stairs. All of this going on at once is known as “metabolic syndrome.”

With apologies to Indiana Jones, it’s not the years or the mileage — it’s the biological context!
Robinson WH, Lepus CM, Wang Q, et al. Low-grade inflammation as a key mediator of the pathogenesis of osteoarthritis. Nat Rev Rheumatol. 2016 10;12(10):580–92. PubMed 27539668 ❐ PainSci Bibliography 52712 ❐
Weng Q, Goh SL, Wu J, et al. Comparative efficacy of exercise therapy and oral non-steroidal anti-inflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomised controlled trials. Br J Sports Med. 2023 Jan;57(15):990–996. PubMed 36593092 ❐ PainSci Bibliography 51421 ❐
This enormous meta-analysis concludes that exercise is a modestly effective treatment for hip/knee arthritis in the short term:

Exercise has similar effects on pain and function to that of oral NSAIDs and paracetamol. Given its excellent safety profile, exercise should be given more prominence in clinical care, especially in older people with comorbidity or at higher risk of adverse events related to NSAIDs and paracetamol.

The data also shows diminishing returns over time, dwindling to a trivial benefit.

But this data shows that exercise is quite safe and somewhat helpful — and therefore also obviously not harmful.

This is not surprising science, of course. That conclusion is based on one-hundred and fifty-two trials. 😮 That is a whole bunch of trials! The effect of exercise on arthritis is one of the better studied questions in the science of pain. We have seen this result before, many times. But it’s nice to see the data synthesized in a mighty meta-analysis for the BJSM.

Nor is it especially exciting science: pain relief in the same league as the common pain meds isn’t exactly dazzling stuff. Last I checked, no one was claiming that their ibuprofen is a miracle cure for their arthritis. Also, your mileage may vary in a big way; not everyone is going to get a pain-relief benefit from a workout, and some will actually get the opposite (“exercise intolerance” is common in people with chronic pain). But ibuprofen can fail and backfire too… and, hoo boy, that stuff is a lot more dangerous than exercise (see Bally), and many people cannot take NSAIDs at all.

The important conclusion here is that exercise might actually help arthritis, and definitely doesn’t generally make it worse.
Holden MA, Hattle M, Runhaar J, et al. Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis. The Lancet Rheumatology. 2023 Jul;5(7):e386––e400. PubMed 38251550 ❐ PainSci Bibliography 51623 ❐
The calorie-counting stairs (click to zoom). Stairs are the most ubiquitous, accessible “gym equipment” in the world

It has been said that exercise is the closest thing there is to a miracle cure. “All the evidence suggests small amounts of regular exercise (five times a week for 30 minutes each time for adults) brings dramatic benefits,” we “age well” when we are active (Gopinath): less anxiety (Schuch), prevention of dementia (Smith) and a laundry list of other diseases (Pedersen), and as little as just 10 minutes per week might push back death itself (Zhao). It’s also superb for sleep quality (Giannaki). It may even be good medicine for musculoskeletal injuries (more info).

But why is it so awesome? Exertion mobilizes extensive networks of biological resources that are relatively dormant while we’re watching Netflix. It’s biologically “normalizing,” pushing systems to work the way they are supposed to work. Exercise cannot normalize everything, but it does stimulate an incredibly broad spectrum of biological function — way more than any medicine, supplement, or superfood.
There are two main kinds of pain: nociceptive and neuropathic. Nociceptive pain is the most familiar because it arises from damaged tissue, like a cut or a burn. Neuropathic is more rare, because it is caused by damage to the damage-reporting system itself, the nervous system. Some pain, like fibromyalgia pain, doesn’t fit into either category, and was historically and poorly labelled “functional pain,” now most commonly called “nociplastic.” Pain is also either somatic (skin, muscle, joints) or visceral (organs). See The 3 Basic Types of Pain: Nociceptive, neuropathic, and “other” (and then some more).
Pain is a volatile, unpredictable experience that may often be exaggerated by an overprotective brain. If the brain produces all pain — and technically it does, just like it produces everything else — maybe that means we can think pain away? Probably not with pure willpower or an attitude adjustment, no, but we may be able to influence pain, indirectly, if we understand it — a few Jedi pain tricks. This isn’t about treating the root causes of pain, but tinkering with the perception of it. Pain is fundamentally an alarm, and maybe we can convince our brains that it doesn't need to be so loud, with methods like increasing confidence through education about pathology and pain itself (“Explain Pain”), avoiding nocebo, limiting “pain talk,” and many more. These are not easy or proven paths to pain relief, but all of them have some potential. See Mind Over Pain: Pain can be profoundly warped by the brain, but does that mean we can think the pain away?